Sample Limited Power of Attorney

IN THE CIRCUIT COURT FOR PRINCE GEORGE’S, MARYLAND

Ari Gold - Plaintiff
v
Dr. Vincent Chase- Defendant

CASE NO.: 24-C-05-026677 OT

Limited Power of Attorney

The undersigned, Ari Gold, hereby appoint RONALD V. MILLER, JR., of Miller & Zois, LLC, as my true lawful attorney to endorse a settlement check from USAA in the amount of $496,000.00 arising out of an automobile accident on July 15, 2013. We further direct our attorney to disburse the settlement as follows:

powerofattorney

TOTAL SETTLEMENT: $496,000

Deductions:

Attorneys' Fees $165,167
Attorneys' Expenses (see attached): $1,488.33

Outstanding Medical Bills: $0
Blue Cross Lien: $85,301
Total Deductions: $251,956.33

DISBURSEMENT TO MR. GOLD: $244,043

___________________
Date | Ari Gold

STATE OF MARYLAND :
COUNTY OF HOWARD :

I HEREBY CERTIFY that on this day of __________, 2007, personally appeared Ari Gold, and made oath in due form of law that the matters and facts set forth in the aforegoing Limited Power of Attorney are true and correct to the best of her knowledge, information and belief.

Notary Public
My Commission Expires:

  • More Sample Attorney Forms
  • Get a Sample Demand Letter

Contact Us For a Free Consultation

If you are hurt in a serious accident or are the victim of medical malpractice, contact our team of lawyers to discuss your case.
Call us now for help at (800) 553-8082

You can also get a FREE no obligation on-line consultation.